Anesthesiologists As Operating Room Directors: Results of a Survey Steven Boggs1*, Elizabeth Frost1 and Jessica Feinleib2

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Boggs et al. Int J Anesthetic Anesthesiol 2016, 3:041 DOI: 10.23937/2377-4630/3/1/1041 International Journal of Volume 3 | Issue 1 Anesthetics and Anesthesiology ISSN: 2377-4630 Research Article: Open Access Anesthesiologists as Operating Room Directors: Results of a Survey Steven Boggs1*, Elizabeth Frost1 and Jessica Feinleib2

1Department of Anesthesiology, Icahn Medical School at Mount Sinai, New York, USA 2Department of Anesthesiology, Yale Medical Center, New Haven, USA

*Corresponding author: Steven Boggs, Department of Anesthesiology, Icahn Medical School at Mount Sinai, New York, NY 10029, USA, E-mail: [email protected]

time first case start and transparency of OR utilization are just some Abstract of these factors [2-4]. Background: Many ideas have gone into the development of the concept of the Perioperative Surgical Home (PSH) and To underscore the importance of surgery and procedures for Enhanced Recovery after Surgery (ERAS). Many anesthesiologists facilities, a recent study demonstrated that cancelled surgeries have a have advocated for an increased role in operating room (OR) highly significant financial impact on hospitals ($4,500/cancelled case) management, advancing from OR managers to OR directors with [5]. Managing an OR requires both medical and business acumen. For greater decision making and improved means of communication. OR directorship, though, many other attributes are required including However, there is little uniformity at present in the running of ORs around the country. leadership over the entire perioperative process, a collaborative work ethic and the ability to understand and enforce policies and Methods: In an attempt to better understand how ORs are run and to gauge the response and attitude of both academic and procedures, ensuring that Standards of Care are known and followed, as general practice anesthesiologists to playing an increased role, we demonstrated in some recent job application sites [6,7]. performed an international literature review, followed by a survey Historically, either surgeons or anesthesiologists have acted as both by internet and at a national meeting. medical managers in ORs. These individuals have focused primarily Results: Of 19 identified articles, 7 were from primarily non-English on ensuring that facilities have met medical standards of care (a legal speaking countries. All articles noted that rational management of term). Operating room directors, in contrast, have typically come the OR requires appropriate data collection to make both strategic and tactical decisions. The E mail and meeting survey garnered from nursing services and these individuals have usually been tasked 350 responses. Analysis indicated that the OR was managed with improving turnover and other metrics of performance in the by an anesthesiologist in 52% of cases, by a nurse in 46%, by operating suite. Unfortunately, the objectives that nurses who are OR a surgeon in 18% and by a team approach in 18%.Only 34% directors pursue may not reflect those most significant to the facility, responded that the OR leaders had any training in management. as they tend to focus rather on reduction of under-utilized OR time An overwhelming 94% gave a positive response to the query about and nursing labor costs instead of total revenue and contribution whether anesthesiologists possess the skills to be OR directors as margin to the facility as well as other more focused medical issues [8]. either the team leader or as part of a team. While 71% were aware of PSH/ERAS, only 34% used these models. With the development of the Perioperative Surgical Home Conclusions: Almost all the anesthesiologists polled believed that (PSA) and Enhanced Recovery after Surgery (ERAS), a compelling they were in the best position to direct the OR. Complex skills are argument might be made that anesthesiologists should assume required and currently are not adequately taught. overall leadership in the OR. For example, as Dexter et al point out, anesthesiologists have several principle opportunities for net cost Introduction reduction by eliminating unnecessary interventions that do not have the potential to benefit patients (e.g. routine preoperative testing), Management of operating rooms (OR) has become increasingly decreasing fresh gas flows with inhalational agents and optimizing staff complicated over time. Case scheduling and time management assignments [9]. The objectives of an anesthesia group are to maximize in the OR suite have always been critical skills, but knowledge of case production and efficiency and minimize OR downtime. These and compliance with hospital, state and national regulations and objectives mirror those of the facility. Anesthesiologists would seem budgetary matters have grown in importance, complexity and to have ideal backgrounds to serve both as medical directors of the significance to hospitals. The OR accounts for up to 60% of the OR and as overall OR directors because their work place is primarily revenue of a facility and up to 40% of its expenses [1]. Numerous in the OR suite and they interact with all surgical and procedural factors in the perioperative period can and must be optimized to services. Increasingly their work also involves provision of services improve patient safety as well as both patient and surgeon satisfaction at off-site, non-OR locations. In addition, anesthesiologists organize and increase profit margins. Improved scheduling to add greater staff scheduling, often for very large departments, and manage large efficiency, standardization of processes, especially as regards to drug capital budgets. Most importantly, however, it is in the best interests management, better operational reporting, clearer throughput, on of anesthesiologists and facilities to minimize underutilized OR time.

Citation: Boggs S, Frost E, Feinleib J (2016) Anesthesiologists as Operating Room Directors: Results of a Survey. Int J Anesthetic Anesthesiol 3:041. doi.org/10.23937/2377-4630/3/1/1041 ClinMed Received: December 18, 2015: Accepted: January 28, 2016: Published: January 30, 2016 International Library Copyright: © 2016 Boggs S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. DOI: 10.23937/2377-4630/3/1/1041 ISSN: 2377-4630

However, many anesthesiologists feel they are already receive refresher training in statistics and then learn to both gather overburdened, especially balancing work and family. For this reason data and make decisions based on the data so obtained. Examples of we sought to devise a pilot study to assess attitudes of anesthesiologists the case studies from the course include: to the concept of assuming the greater responsibilities of OR • Anesthesia preoperative evaluation clinics directorships. • Decision-making on the day of surgery Methods • Service-specific operating room staffing Our study involved two parts. The first was a literature review; the second a survey. For the literature review, we worked with the • Operating room financial assessment for tactical decision- reference librarian at the Levy Library at the Icahn School of Medicine. making A search was conducted in the English, French, German and Spanish • Economics of reducing turnover times literature with the following keywords: • Economics of anesthetic agents • Anesthesiologist(s) as operating room director • Strategic planning: financial impact of different types of • Anesthesiologist(s) + operating room director surgery • Anesthesiologists + running the operating room • Anesthesiologist and nurse anesthetist staffing • Nurses as operating room director • Physician agreements - Anesthesia support & surgeon blocks • Nurse + operating room director • Showing differences among hospitals and their surgical • Nurse + running the operating room practices • Operating room (OR) Director A recent survey of anesthesiology training programs revealed that • Anesthesiologist + operating room (OR) director while residents and program directors felt that they received adequate instruction in quality management and OR scheduling, they did not • Medical Director + operating room (OR) (surgeon, receive enough training in actual practice management - particularly as anesthesiologist) it pertains to cost containment [25]. Only a few established programs In addition, general search engines were used to identify available in the Management of Perioperative Services exist (Stanford, MGH, residency and post-residency training programs in OR management Irvine, and Columbia). Most residents finish their training, believing in all specialties. that they know how to “run the board,” which involves triaging cases and assigning anesthesia staff. However, without testing this For the survey, in November 2014 an e-mail questionnaire was assumption cannot be made [21,22]. Moreover, most residents do not sent to all anesthesiologist registrants at the Post Graduate Assembly graduate with significant understanding of OR management, which (PGA) meeting of the New York State Society of Anesthesiologists includes leadership skills, logistics, communication systems and (NYSSA) in New York. Information sought consisted of basic understanding of the financial and accounting skills for efficiently demographic data, OR management at individual facilities, views managing an OR suite. Such a skill-set differs radically from the on the role of the anesthesiologist in that position and use and didactic programs that are the norm. familiarity with PSH/ERAS. Additional data were collected by direct yes or no voting at a scientific booth at the meeting, with the same Regarding our NY State Society of Anesthesiologist Survey at questionnaire. Participants were asked not to fill out the electronic the PGA, of the 3069 anesthesiologist registrants 280 responded. An survey at the booth if they had previously completed it online. additional 70 voted directly. Results are as follows: Results • 52% stated that an anesthesiologist managed their OR 46% stated that a nurse managed their OR Our literature search found nineteen (19) articles that met our • search criteria since 1998. Of these, seven (7) were from non-primarily • 16% stated that a surgeon was currently managing their OR. English-speaking countries. The work of Dexter and colleagues constituted two (2) of the articles from the English literature [8,10]. • 18% noted team management. The US literature had a slight tilt toward data-driven management • 71% were familiar with PSH/ERAS, but only of the OR while the European literature tended to focus more on the questions of “who” should manage the OR [11-16]. All articles • 34% used these models cited an underlying theme that rational management of the operating Multiple metrics were measured at most facilities (Figure 1). room requires appropriate data collection to make both strategic These factors included documentation of first-time start performance, and tactical decisions [17]. The OR manager cannot make optimal turnover time and room utilization. In 2% of facilities, no metrics decisions without basic data. Yet, learning how to obtain these data were measured. Sixty-40% of respondents thought that OR directors and then act on them is not intuitive to any manager - surgeon, should use management techniques and fiscal decision making skills. nurse or anesthesiologist [18,19]. For example, Wang et al performed However, only 34% of respondents stated that their OR managers a behavioral study of daily mean turnover times and first case start had any management training and of that number only 8% had 1-2 times [20]. They found that overall, the staff worked just as quickly on years of training either in attending courses or completing advanced days with few or many hours of cases with no slow down apparent. programs and/or degrees in business or hospital management. Manual Other data have focused on managerial decisions by anesthesiologists voting plus the survey results pointed to a 94% positive response to that resulted in increased clinical work with over-utilized OR times, the query about whether anesthesiologists possess the skills to be higher staffing costs and unpredictable work hours that could OR directors as either the team leader or as part of a The voting also mandate overtime [21-22]. The authors suggest that enterprise-wide indicated that in this study population, responsibility for the overall scheduling cab coordinate anesthetics with other appointments direction of the operating room was considered the responsibility of on the same date and improve consistency and accuracy of patient anesthesiologists, nurses and then surgeons 52%, 45% and 18% of the instructions [23]. time, respectively (Figure 2). To address these and other deficiencies an intensive 4-day course Discussion in OR Operations Research is conducted at the University of Iowa [24] This course is an intensive 4-day course in which participants Managing operating suites requires multiple high-level skills.

Boggs et al. Int J Anesthetic Anesthesiol 2016, 3:041 • Page 2 of 4 • DOI: 10.23937/2377-4630/3/1/1041 ISSN: 2377-4630

4. Establishment of protocols for the management of patients Q7 Does your operating room/suite in all stages of surgery to promote quality, safety and cost- measure any of these metrics? Please select effective delivery of care all that apply. Answered: 191 Skipped: 10 5. Ensuring adequate anesthesia personnel are available to cover the daily surgical schedule Pationt Walt Times 6. Enforcing standards of care within guidelines of regulatory Pationt Walt Times agencies

After Hours Room Uso 7. Safeguarding the fiscal integrity of the program

Cost of The duties of an OR director are different and require additional Supplies training. The duties of an OR director include [26]: Room/Department /Surgeon... 1. Overseeing the management of perioperative services

Cost of Unused Nurse/Anesth... 2. Coordinating, facilitating and managing changes within the

First case perioperative services start time 3. Collecting and analyzing data related to quality, performance OR turnover time or cost improvement projects as they apply to perioperative

Cancellation services rate

Scheduling 4. Use of conflict resolution techniques as a leader of a Accuracy multidisciplinary team None 5. Evaluation of performance of perioperative personnel

Other (please specify) 6. Interview techniques for personnel selection

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7. Ensuring that personnel, equipment and supplies are available Figure 1: Multiple metrics were measured at most facilities. for all perioperative services 8. Coordination of advanced project management with principals. Q6 Who is responsible for the overall 9. Conveying the mission of the organization direction of your operating rooms/suite? Please select all answers that apply. When asked, the majority of anesthesiologists believe that they Answered: 191 Skipped: 10 are suited to be OR directors. However, as the above list illustrates, managerial techniques, personnel management, quantitative analysis Nurse and behavioral managerial tools are skills required to successfully

Surgeon function as an OR director. Most anesthesiologists are capable of mastering this body of knowledge but additional education is Anestheslologis t required to become fully competent in these areas.

Managar There are inherent difficulties in searching out information on Physician (N... OR management as many people making management decisions do Managar Business not read published literature, rather relying on colleague advice [27]. On-line help files may be complicated to navigate with specialized Team vocabularies, unique to the application. In addition, to date, there are

Other (please very few articles that address specific subject areas such as anesthesia specify) group management. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% It is not surprising that up to now the selection of both medical Figure 2: The majority of anesthesiologists believe that they are suited to directors and OR directors for operating suites has been a local be OR directors. decision. Previously, no specific training background has been identified for these positions. However, to improve both financial Leadership attributes are essential to harness the efforts of a well and operational metrics for facilities, the ability to both measure and diversely trained workforce. Yet, because ORs function as appropriate indicators and to make decisions on that data will become significant revenue sources, an OR director must also be able to both increasingly important. The costs of hiring an ill suited person or gather the requisite data needed for efficiency while appreciating the losing valuable staff members due to poor management will continue interventions needed to accomplish those goals. Residency programs to grow. Ensuring continuous supply of material to the OR will be train clinicians to function as excellent clinical anesthesiologists, but more challenging with just-in-time delivery and more complicated most graduates do not feel that they complete residency programs informational technology ordering systems. with the skill-set to competently manage complex ORs efficiently. Our study is admittedly skewed in that we surveyed only Anesthesiologists generally finish training and enter practice with anesthesiologists, not nurses and surgeons. Our initial aim was to the basic skills required to be OR medical directors. These essential gauge the interest of anesthesiologists in expanding their role in the skills include: OR, especially in the light of the PSH/ERAS initiative. Admittedly the response rate was low but that is not uncommon in electronic 1. Daily management of the operating room schedule surveys today. As a pilot study the positive information obtained will 2. Planning for patients in the pre-, intra-, and postoperative be used to design studies of other groups that also have significant involvement and interest in the management of operating suites, stages of surgery including surgeons and nurses. Going forward we will partner with 3. Work ethics to assure effective and appropriate use of OR colleagues in these specialties to explore the level of training and resources interest among surgeons and nurses for operating room management.

Boggs et al. Int J Anesthetic Anesthesiol 2016, 3:041 • Page 3 of 4 • DOI: 10.23937/2377-4630/3/1/1041 ISSN: 2377-4630

We believe that the time has come to raise awareness of the Anaesthesist 52: 1062-1067. capability of anesthesiologists to assume broader leadership in the 15. Marjamaa R, Vakkuri A, Kirvelä O (2008) Operating room management: why, operating suite. Anesthesiologists already understand the flow from how and by whom? Acta Anaesthesiol Scand 52: 596-600. pre-operative assessment through the operating suite and other non- 16. Marty J, Plaud B (2009) Anesthetic process, organization, management and operating room locations all the way through the post-operative economic issues: the French perspective. Curr Opin Anaesthesiol 22: 249- recovery phase. They spend their entire workday in this environment 254. and are already familiar with many of the roadblocks to process 17. Baumgart A, Schüpfer G, Welker A, Bender HJ, Schleppers A (2010) Status improvement. And, they are familiar with the necessary standards of quo and current trends of operating room management in Germany. Curr perioperative care. Opin Anaesthesiol 23: 193-200. 18. Wang J, Yang K (2014) Using type IV Pearson distribution to calculate However, anesthesiologists or anyone who assumes management the probabilities of underrun and overrun of lists of multiple cases. Eur J of an operating room suite must add to their medical knowledge Anaesthesiol 31: 363-370. with education in operations, finance, accounting and personnel 19. Sanford JA, Macario A (2014) Data, data, on the server: challenges in management to serve as effective leaders in the role of operating room applying data analysis to operating room management. Anesthesiology 121: directors. The clinical significance of this is that when functioning in 6-8. this capacity, the individual is not ensuring the welfare of only an 20. Wang J, Dexter F, Yang K (2013) A behavioral study of daily mean turnover individual patient but rather that of an entire group of patients. If the times and first case of the day start tardiness. Anesth Analg 116: 1333-1341. OR suite is not managed efficiently, it can limit the care a hospital can 21. Dexter F, Lee JD, Dow AJ, Lubarsky DA (2007) A psychological basis for provide [28]. anesthesiologists’ operating room managerial decision-making on the day of surgery. Anesth Analg 105: 430-434. While no particular background in and of itself can prepare 22. Dexter F, Willemsen-Dunlap A, Lee JD (2007) Operating room managerial someone for these positions, with the correct training anesthesiologists decision-making on the day of surgery with and without computer may be ideal candidates. Moreover, as major proponents of recommendations and status displays. Anesth Analg 105: 419-429. the Perioperative Surgical Home (PSH), such leadership allows 23. Dexter F, Xiao Y, Dow AJ, Strader MM, Ho D, et al. (2007) Coordination anesthesiologists to further contribute to patient welfare, efficiencies of appointments for anesthesia care outside of operating rooms using an for hospitals, cost-minimization and increased throughput. enterprise-wide scheduling system. Anesth Analg 105: 1701-1710, table of Conducting a similar survey at a national surgical or nursing meeting contents. should offer increased insight. 24. Wachtel RE, Dexter F (2010) Curriculum providing cognitive knowledge and problem-solving skills for anesthesia systems-based practice. J Grad Med In sum, this study points out that OR managers require advanced Educ 2: 624-632. training in business. It needs to be investigated if any one primary 25. Kalarickal PL, Stain E, Rieff B, Fox CJ, Rosinia FA (2012) Practice specialization is optimal preparation for managing an OR. Further Management Education in Anesthesiology Training programs is not research across disciplines (nursing, surgery and anesthesiology) is Adequate: The Results of a Survey of the ASA Membership. Abstracts. ASA required to answer this question. However, in a period of significant Practice Management (PM) PM19. cost pressures and declining reimbursement, the need for optimal 26. Director of operating room, job description. Roosevelt General hospital. operating suite function is more important than ever to ensure safe 27. Difficulties and challenges associated with literature searches in operating and appropriate provision of service to patients. room management, complete with recommendations. Anesth Analg 117: 1460-1479.

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